Modern Treatment of Spinal metastases Maxwell Boakye, MD MPH FACS FAANS Associate Professor of Neurosurgery Nelson Endowed Chair Center for Advanced Neurosurgery, University of Louisville

My Background Neurosurgeon Residency 2002 Fellowships-complex spine-Emory and Spine Oncology-Sloan Kettering-2003 Stanford-2003-2010-worked with cyberknife Special interest in spine tumors and spine radiosurgery

Goals Epidemiology Presentation Imaging Role of Surgery Emerging Treatment paradigms Decision making and Frameworks Memorial Sloan Kettering NOMS criteria Cases

Epidemiology 20000 new cases of metastatic epidural cord compression each year 10% of cancer patients will develop spinal metastatic About 70% of all cancer deaths occur in elderly patients aged over 65 Postmortem studies metastases present in 90% of patients with systemic cancer

Epidemiology Number of elderly patients dying from cancer will double by 2030 By age 2050, the number of newly diagnosed patients aged 85 will quadruple

Myelopathy-Motor, Sensory, Bowel/Bladder Pain Signs and symptoms Myelopathy-Motor, Sensory, Bowel/Bladder Usually from epidural cord compression Pain Biologic nocturnal/early morning-resolves during day-usually from tumor infiltration, Steroid responsive Mechanical-movement related Radicular-usually epidural disease in foramen Other Symptoms e.g LOC or AMS from brain

Imaging X-rays CT MRI PET

Imaging findings Imaging Epidural disease only Vertebral disease only Vertebral disease with epidural Cord compression Mechanical instability Pathological fractures Single level, Multiple level, Distant metastases

Treatment options Surgery Radiation therapy Radiosurgery Chemotherapy

Main surgical approaches Anterior Transthoracic, Retroperitoneal Posterior Laminectomy Posterior transpedicular, costotransversectomy approach

Epidural Compression: Surgery is superior to radiation Patchell et. al, Lancet Vol 366: 643-648, 2005

Patchell study

Surgery vs. radiation-Patchell

Surgery improves quality of life outcomes Quan et. Al., Eur Spine Journal 2011 Jun 26

Surgical complications

Price of surgery: High Morbidity and mortality Complication rates-20-40%

Emerging Treatment Patterns Vertebral augmentation Vertebroplasty Kyphoplasty Radiosurgery Combined kyphoplasty and radiosurgery

KYPHOPLASTY

KYPHOPLASTY

CAFÉ TRIAL

CAFÉ trial

Berenson et. Al., Lancet Oncology 2011 Mar;12(3):225-35.

CYBERKNIFE RADIOSURGERY The CyberKnife® a robotic manipulator to move a compact linear accelerator with six degrees of freedom Real-Time Image Guidance Throughout the Treatment Dynamic Motion Tracking Allows for accuracy and conformality Louisville is getting one!!

Other radiosurgery systems

Concept of Separation surgery

Separation surgery

DECISION MAKING Who should be operated on? Frameworks for prognosis Algorithms and Decision aids

Tokuhashi score 􀂃≥9:•Excision•Survival > 12 months 􀂃≤5:•Palliative•Survival < 3 months

Decision Making-NOMS criteria Neurologic Oncologic Mechanical Systemic

NOMS criteria Neurologic-myelopathy, degree of epidural cord compression Oncologic- radiosensitivity of tumor Mechanical instability-movement related pain Systemic disease and medical comorbidities

Neurologic-Classification of Epidural compression

Neurologic-Classification of epidural compression Bilsky M, Hematol Oncol Clin N Am 20 (2006) 1307–1317

Oncologic-Radiosensitivity –Myeloma & Lymphoma: most radiosensitive –Prostate, Breast, Lung and Colon: moderately –Thyroid, Kidney, Melanoma: not radiosensitive

Mechanical Instability

Systemic factors

SINS score Ranges 0-18 0-6, Stable 7-12, indeterminate, possibly impending instability 13-18-Instability Surgical consultation is recommended for SINS score > 7. Fisher CG, Spine Vol 35(22): 1221-1229, 2010

Oncologic factors-Impact of Comorbidities

Oncologic and Systemic factors-survival

Predictors of Survival VAriable Hazard ratio 95% CI P-value Age 1.001 0.99-1.02 0.90 Ambulatory status 2.355 1.52-3.66 0.0001 Cervical mets 1.07 0.69-1.65 0.76 Comorbidity 2.96 1.34-6.51 0.007 Epidural compression 1.20 0.69-2.09 0.52 Pathologic fracture 1.41 0.95-2.08 0.08 Radiosensitivity 2.56 1.67-3.91 <0.0001 Radiotherapy 0.98 0.67-1.43 0.91 Urinary incontinence 1.16 0.78-1.71 0.47 Visceral mets 1.09 0.75-1.57 0.65

NOMS decision framework. Bilsky M, Hematol Oncol Clin N Am 20 (2006) 1307–1317